I got a call yesterday from a woman who takes a lot of insulin to control her diabetes. She said she went to pick up her insulin at the pharmacy and was told her cost would be $340 – which is eight times what it has been.
She asked me if I can help her with her Medicare Advantage plan because there must be some mistake. Unfortunately, I cannot help her because this price jump is not a mistake.
I told her she is most likely in the donut hole/coverage gap. I also told her that her Medicare Advantage plan sends her a statement each month that shows what the plan has spent on her prescriptions and how close she is getting to the coverage gap.
Selena is getting sticker shock because her co-pay for her insulin has been $40 per month – but her plan has been paying $766 for two boxes of flexpens. Now that she is in the donut hole, she gets a 55% discount on the retail price of the pens, but that is $340.
Selena said she is in a “Special Needs” Medicare Advantage plan for people with diabetes. That doesn’t sound very “special” to me!
Selena is 82 years old and has a pension, so she makes too much money to get help with her drug costs. She is not sure she can afford to pay $340 each month for her insulin – and she has not yet picked up her other prescriptions, which will also cost more now that she is in the donut hole.
She said she was shocked when the pharmacist told her what she had to pay for her insulin. “I felt like somebody punched me in the stomach”, she said.
Selena is legally blind, so she needs to use a “flex pen” for her insulin. The pen makes it easy to adjust the insulin amount she gives herself three times per day.
“What can I do?”, she asked. I did not have an answer for her.
She says she has checked into the patients’ assistance program through the drug company, but her income is too high (about $30,000 per year). She says she has called the two congressional offices in Tucson, but they have not offered help.
“I am so worried about this”, Selena said. “It takes away any joy in my life because I don’t know how I’m going to pay all my bills and pay for my insulin.”
I have also written about how people can get help with their drug costs if their income is low enough. Selena makes too much money for these programs.
Unfortunately, I had no advice for Selena on how to get help with her insulin costs while she is in the donut hole. We both agreed that it is crazy that the cost of insulin is so high when it is absolutely necessary for Selena to stay healthy. If she can’t afford her insulin and doesn’t take it, she will end up sicker and will cost her Medicare Advantage plan a lot of money. Dialysis is incredibly expensive – and that’s where people end up who do not control their diabetes.